History of Present Illness:
A pleasant woman in her mid-90’s presents to the hospital with 2 days of worsening atraumatic left wrist pain. She denies any fever, injury or history of same but she does have to push hard to get up out of her chair.
Vital Signs & Physical Exam:
Vital signs are normal except for
Physical exam is otherwise normal except for
Initial Diagnostic Testing:
- CBC: normal e
- Chem-7: normal
- Imaging:
What is the LEAST likely diagnosis?
- A) Osteoporosis
- B) Chondrocalcinosis
- C) Pseudogout
- D) Wrist fracture
SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT
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ANSWER:
- A) Osteoporosis – common at this age and seen on x-ray
- B) Chondrocalcinosis – not easily seen but present on x-ray
- C) Pseudogout – this is a classic presentation and there is B) to support it
- D) Wrist fracture – CORRECT: there is no fracture present
1-Minute Consult on this topic: Click HERE and scroll to the MIDDLE of page 291.
CASE CONCLUSION: Tap was dry so CT was ordered to rule out an occult fracture since she had e/o osteoporosis on x-ray. CT showed soft tissue swelling without an effusion but erosions consistent with pseudogout
EXTENSIVE CHONDROCALCINOSIS OF THE WRIST WITH SOME EROSIONS MAY REPRESENT CPPD CRYSTAL DEPOSITION DISEASE.
SEVERE OSTEOARTHRITIS OF THE FIRST CARPOMETACARPAL JOINT.
OSTEOPOROSIS WITHOUT EVIDENCE OF ACUTE FRACTURE.
CASE LESSONS: The classic presentation of pseudogout is severe unilateral atraumatic wrist pain in an elderly patient. X-rays may show chodrocalcinosis, especially if a knee x-ray is done. This is the first case I have had with a dry tap. I have had about 8 other cases with a diagnostic tap